Chronic and Recurrent Abdominal Pain Paul E. Hyman, MD* *Louisiana State University Health Sciences Center and Children’s Hospital of New Orleans, New Orleans, LA. Education Gap The past 20 years have witnessed a transition in clinical understanding of childhood bellyaches. The recently published third iteration of pediatric Rome criteria provides updated and accurate criteria for symptom-based diagnosis of chronic and recurrent abdominal pain. In many cases, primary care clinicians can make symptom-based diagnoses and initiate treatment on the first visit. Objectives After completing this article, readers should be able to: 1. Make symptom-based diagnoses of functional abdominal pain disorders. 2. List a variety of treatment options for children with functional abdominal pain. 3. Recognize warning signs that discriminate disease from functional abdominal pain. 4. Understand how psychosocial factors play a role in disability associated with functional abdominal pain. EPIDEMIOLOGY By definition, chronic or recurrent abdominal pain must occur at least 4 times each month for at least 2 months. Abdominal pain complaints begin as soon as a child can provide an accurate pain history, usually around age 7 years but occa- sionally younger. Before that age, children have difficulty separating emotional distress from physical pain. The differential diagnosis of child and adolescent abdominal pain is unrelated to age. One in 10 children visits a clinician because of chronic or recurrent abdominal pain. (1) How can a clinician screen quickly for disease? The first consideration is the duration of each episode. If the pain lasts less than 5 minutes, even if it occurs many times daily, the pain is unlikely to be worrisome. Abdominal pains lasting just a few minutes may be abdominal wall muscle cramps or high-amplitude- propagating colon contractions. High-amplitude-propagating contractions are waves of muscle contraction starting in the ascending colon, with pressures greater than 60 mm Hg, that move colonic contents through the colon to the rectum. (2) High-amplitude-propagating colon contractions are normal, but they cause an urge to defecate for about 2 minutes several times daily. Children who AUTHOR DISCLOSURE Dr Hyman has disclosed no financial relationships relevant to this article. This commentary does contain a discussion of an unapproved/investigative use of a commercial product/device. Vol. 37 No. 9 SEPTEMBER 2016 377 by guest on January 28, 2017 http://pedsinreview.aappublications.org/ Downloaded from
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Chronic and Recurrent Abdominal PainPaul E. Hyman, MD*
*Louisiana State University Health Sciences Center and Children’s Hospital of New Orleans, New Orleans, LA.
Education Gap
The past 20 years have witnessed a transition in clinical understanding of
childhood bellyaches. The recently published third iteration of pediatric
Rome criteria provides updated and accurate criteria for symptom-based
diagnosis of chronic and recurrent abdominal pain. In many cases,
primary care clinicians can make symptom-based diagnoses and initiate
treatment on the first visit.
Objectives After completing this article, readers should be able to:
1. Make symptom-based diagnoses of functional abdominal pain
disorders.
2. List a variety of treatment options for children with functional
abdominal pain.
3. Recognize warning signs that discriminate disease from functional
abdominal pain.
4. Understand how psychosocial factors play a role in disability associated
with functional abdominal pain.
EPIDEMIOLOGY
By definition, chronic or recurrent abdominal pain must occur at least 4 times
each month for at least 2 months. Abdominal pain complaints begin as soon as a
child can provide an accurate pain history, usually around age 7 years but occa-
sionally younger. Before that age, children have difficulty separating emotional
distress from physical pain. The differential diagnosis of child and adolescent
abdominal pain is unrelated to age.
One in 10 children visits a clinician because of chronic or recurrent abdominal
pain. (1) How can a clinician screen quickly for disease? The first consideration is
the duration of each episode. If the pain lasts less than 5 minutes, even if it occurs
many times daily, the pain is unlikely to be worrisome. Abdominal pains lasting
just a few minutes may be abdominal wall muscle cramps or high-amplitude-
propagating colon contractions. High-amplitude-propagating contractions are
waves of muscle contraction starting in the ascending colon, with pressures
greater than 60 mm Hg, that move colonic contents through the colon to the
rectum. (2) High-amplitude-propagating colon contractions are normal, but they
cause an urge to defecate for about 2 minutes several times daily. Children who
AUTHOR DISCLOSURE Dr Hyman hasdisclosed no financial relationships relevant tothis article. This commentary does contain adiscussion of an unapproved/investigativeuse of a commercial product/device.
Vol. 37 No. 9 SEPTEMBER 2016 377 by guest on January 28, 2017http://pedsinreview.aappublications.org/Downloaded from
TABLE 1. Rome Criteria for the Pediatric Pain-associated FunctionalGastrointestinal Disorders (15)*
FUNCTIONAL DYSPEPSIA (FD)
Must include 1 or more of the following bothersome symptoms at least 4 times a month for at least 2 months prior to diagnosis:
1. Postprandial fullness
2. Early satiation
3. Epigastric pain or burning not associated with defecation
4. After appropriate evaluation, the symptoms cannot be fully explained by another medical condition
Within FD, the following subtypes are now adopted:
1. Postprandial distress syndrome includes bothersome postprandial fullness or early satiation which prevents finishing a regular meal.Supportive features include upper abdominal bloating, postprandial nausea, or excessive belching.
2. Epigastric pain syndrome includes all of the following: bothersome (severe enough to interfere with normal activities) pain or burninglocalized to the epigastrium. The pain is not generalized or localized to other abdominal or chest regions and is not relieved by defecation orpassage of flatus. Supportive criteria can include: a) burning quality of the pain but without a retrosternal component and b) commonlyinduced or relieved by ingestion of a meal but may occur while fasting.
IRRITABLE BOWEL SYNDROME (IBS)
1. Abdominal pain at least 4 days per month over at least 2 months associated with 1 or more of the following:
a. Related to defecation
b. A change in frequency of stool
c. A change in form (appearance) of stool
2. In children with constipation, the pain does not resolve with resolution of the constipation (children in whom the pain resolves havefunctional constipation, not IBS)
3. After appropriate evaluation, the symptoms cannot be fully explained by another medical condition
Criteria fulfilled for at least 2 months prior to diagnosis
ABDOMINAL MIGRAINE
Must include all of the following occurring at least twice:
1. Paroxysmal episodes of intense, acute periumbilical, midline, or diffuse abdominal pain lasting 1 hour or more (should be the most severeand distressing symptom)
2. Episodes are separated by weeks to months
3. The pain is incapacitating and interferes with normal activities
4. Stereotypical pattern and symptoms in the individual patient
5. The pain is associated with 2 or more of the following:
a. Anorexia
b. Nausea
c. Vomiting
d. Headache
e. Photophobia
f. Pallor
6. After appropriate evaluation, the symptoms cannot be fully explained by another medical condition
Criteria fulfilled for at least 6 months prior to diagnosis
Continued
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onion, inulin), galactans (legumes such as beans, lentils,
soybeans), and polyols (sweeteners containing isomalt, man-
nitol, sorbitol, xylitol, stone fruits such as avocados, apricots,
cherries, nectarines, peaches, plums). FODMAPsmay not be
digested or absorbed well and could be fermented by bacteria
in the intestinal tract when eaten in excess. Typical IBS
symptoms of diarrhea, constipation, gas, and bloating may
improve with a low FODMAP diet. (47) A low FODMAP diet
is best initiated in consultation with a dietitian to assure that
the diet meets the child’s nutritional needs.
Medical FoodsTwo medical foods are on the market to treat IBS. IBGast is
peppermint oil in an enteric-coated capsule. In one pediatric
randomized, controlled trial, peppermint oil was effective
for treating IBS. (48) Dosing is 1 capsule for symptoms 1 to
3 times daily. Bovine serum immunoglobulin taken twice
daily was effective for diarrhea-predominant IBS (d-IBS)
in adults. (49)
Drugs (Table 3)There are no FDA-approved drugs for treatment of chil-
dren with IBS. Randomized clinical trials are missing for
most drugs used for childhood IBS. For example, despite
their routine use by clinicians, there is no evidence that
acid suppression with histamine-2 receptor antagonists
or proton pump inhibitors is helpful in IBS.
Tricyclic antidepressants are effective treatment for
IBS in adults, (50) but 2 randomized, controlled trials in
children were unsatisfying because placebo-treated chil-
dren did as well as amitriptyline-treated children. (51)(52)
However, amitriptyline dosing in the pediatric trials may
have been too low to achieve a response. Amitriptyline and,
to a lesser extent, imipramine are sedating and consti-
pating. If the patient has abdominal pain, diarrhea, and
insomnia, a tricyclic antidepressant may be a good choice
(Table 3).
In children with d-IBS who are unable or unwilling
to take amitriptyline because of concerns about cardiac
arrhythmias, seizures, or mood effects, the serotonin-3
receptor antagonist alosetron is effective. Clonidine may
be a good choice for d-IBS and disordered sleep.
There are several alternatives for children with c-IBS.
A clinician might choose to treat the constipation with
polyethylene glycol titrated to soft stools together with a
Figure 3. Preteens and teens with functional symptoms associated withdisability fall into a gap between conventional medicine andconventional mental health. They require a clinician who understandsfunctional symptoms and a rehabilitation approach to treatment.
Figure 4. Pathogenesis of pain-associateddisability syndrome (PADS). PADS may betriggered by factors causing autonomicarousal in a preteen or teen with a functionalgastrointestinal disorder. From Hyman PE,Bursch B, Sood M, Schwankovsky L, Cocjin J,Zeltzer LK. Visceral pain-associated disabilitysyndrome: a descriptive analysis. J PediatrGastroenterol Nutr. 2002;35(5):663-8.Reprinted with permission from WoltersKluwer Health.
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population, are associated with minor abnormalities in
gastrointestinal motility and sensation, but nearly all
affected patients cope with such disorders without
becoming disabled. In PADS, a developmental, family,
or mental health problem causes sustained autonomic
arousal. The intensity of symptoms and the degree of
disability are proportional to the severity of emotional
distress. PADS severity is inversely correlated with
an individual’s assessment of his or her own academic
or social competence. PADS patients often feel helpless.
Catastrophization, the belief that symptoms can only
worsen and the patient is helpless, further activates auto-
nomic arousal. Similarly, an external locus of control, the
belief that the suffering can be reduced only from outside
sources, interferes with coping and amplifies arousal. Treat-
ment for teens with PADS encompasses a shift away from
the medical model, in which a doctor does something to
cure a passive patient, to a rehabilitation model, in which
clinicians teach the child the necessary skills to return to a
normal lifestyle.
Treatment includes physical therapy, psychotherapy,
and drugs to treat coexisting mental health issues and
sleep disruptions (Fig 5). Psychotherapy and hypnosis have
the advantage of effects that last long after the treatment
period compared to drug effects that last only as long as
treatment continues. Drugs have the advantage of not
requiring a psychotherapist. However, strong evidence
for drug efficacy in children with pain related to FGIDs
is missing. Treatment requires a multidisciplinary biopsy-
chosocial team approach that must include the family.
When the child or family does not accept the diagnosis
or challenges the treatment, management fails. When the
child, family, and team of professionals are in step, treat-
ment succeeds.
References for this article are at http://pedsinreview.aappublications.
org/content/37/9/377.
Summary• On the basis of strong research evidence, most chronic andrecurrent abdominal pain in children and adolescents isfunctional, meaning that symptoms are not feigned, but there isno easily detected disease.
• Symptom-based diagnostic criteria facilitate rapid diagnosis formost children and adolescents with functional abdominal pain.For most children who meet diagnostic criteria for a functionaldisorder and have no warning signs for disease (weight loss,fevers, blood in stool), no testing is necessary or desirable.
• Onthebasisof strongepidemiologicevidence, irritablebowel syndrome(IBS), defined by chronic or recurrent abdominal pain associated withdiarrhea or constipation or alternating diarrhea and constipation, is themost common of the functional gastrointestinal disorders.
• Because of the very few prospective randomized, controlled trialsin children, there is no generally accepted safe and effectivetreatment for IBS in this population. On the basis of strongresearch evidence, treatments for IBS in adults include tricyclicantidepressants and cognitive behavioral therapy.
• On the basis of strong research evidence, the placebo responserate in functional abdominal pain is approximately 40%; thisresponse rate ensures that any treatment works some of the time.
• On the basis of some research evidence and consensus, disabilityfroma functional disorder is proportional to comorbid psychologicaldistress from a mental health disorder or learning disability.
• On the basis of primarily consensus, due to lack of prospectivestudies, treatment for those disabled by functional abdominalpain requires shifting from an acute medical to a rehabilitationmodel and involves a team approach that includes cognitivebehavioral therapy, medication to regulate sleep and reduceautonomic arousal, and physical therapy. Refusal to engage withmental health treatment is associated with treatment failure.
Parent Resources from the AAP at HealthyChildren.org
Chronic and Recurrent Abdominal Pain• https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Abdominal-Pain-in-Children.aspx
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1. A 10-year-old girl is brought by her parents to see you for the first time for evaluation of a 1-year history of abdominal pain that she has been experiencing several times a week. Youknow that chronic recurrent abdominal pain is common among children across the world.You also know that most such pain is not caused by isolated organic disease, but ratherreflects a symptom sparked by a combination of overlapping physical, physiological,mental, and social factors. Which of the following characteristics of the pain will promptyou to initiate an immediate search for an organic explanation?
A. Has a consistent periumbilical distribution.B. Is associated with a 10-lb weight loss.C. Occurs primarily upon awakening.D. Occurs primarily upon going to sleep.E. Occurs several times a day, lasting less than 5 minutes for each episode.
2. Over the past 25 years, the uncovering of a better understanding of the pathophysiology ofchronic and recurrent abdominal pain has:
A. Decreased the need for mental health counseling for the complaint.B. Increased the clinician’s ability to use history and physical examination to reliably
differentiate one functional disorder from another.C. Increased the need for primary care physicians to refer patients with such pain to
gastroenterologists.D. Increased the requirement for sophisticated diagnostic laboratory testing.E. Raised doubt about the role of social stress as a contributing cause.
3. Since starting kindergarten, an 8-year-old boy has had frequent periumbilical pain andnausea in the morning. He occasionally vomits. Which of the following statements wouldstrongly suggest that he suffers from separation anxiety?
A. He has postbreakfast fullness, bloating, and belching.B. He feels fine soon after being permitted to stay home from school.C. His symptoms are present both on weekdays and weekends.D. His symptoms are relieved by defecation.E. His symptoms improve at school as the day goes on.
4. A 12-year-old girl has experienced daily periumbilical abdominal pain lasting several hours forthe past 2 years. She rarely misses school. She has gained weight normally and experiencednormalmenarche. She strains to defecate and passes small hard stools every 2 days, after whichsheexperiences some relief frompainbutnocomplete resolution. Treatmentwithpolyethyleneglycol has failed to resolve the problem. Her physical examination yields normal results. Basedon her history and examination, which of the following is the most likely diagnosis?
5. The caregivers of children and adolescents diagnosed with functional abdominal pain inyour practice ask you about options for treatment and their effectiveness. Assuming that youalready have established a therapeutic alliance with patients and families, provided themwith assurances that you believe that the pain is real, and offered empathy, education, andreassurance, which of the following proposed treatment options currently promises the besttreatment outcome for children and adolescents with functional abdominal pain?
A. Acupuncture.B. Changes in diet.C. Cognitive behavioral therapy.D. Intensive personal psychotherapy.E. Prescription of U.S. Food and Drug Administration-approved medications.
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DOI: 10.1542/pir.2015-01692016;37;377Pediatrics in Review
Paul E. HymanChronic and Recurrent Abdominal Pain
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